You might call it the Washington Woodstock of the Wonks.
Hundreds of members of the health policy establishment gathered in the nation’s capital last Thursday to celebrate the 25th anniversary of the premier health policy journal, Health Affairs, and honor editor-in-chief John Iglehart on his retirement from the position he’s held since the journal’s founding. How a publication whose first issue is dated Winter, 1981 can celebrate a 25th anniversary on the eve of Winter, 2007 was a question that went unanswered. On the other hand, when’s the last time numbers coming out of Washington actually added up?
The day featured a Health Policy Summit filled with a blue-ribbon list of speakers followed by a dinner gala designed to provide
a bit of a financial cushion for a journal highly dependent on the
generosity of a handful of grantmakers. The Summit yielded a number of
interesting nuggets of information, which this blog will address
tomorrow. But just as significant were the insights about the health
policy world that were not explicitly stated. These included:
The creation of an “establishment.” Health Affairs became the premier
journal of health policy in part because its founders deliberately
set out to create a health policy establishment. The conservative do-gooders of Project HOPE recruited
Iglehart, a journalist rather than an academic, to create an analog to
Foreign Affairs, the journal that allows the foreign policy
establishment to talk among themselves. Conspiracy theorists may
suspect Princeton’s Uwe Reinhardt was deliberately groomed as the
health policy answer to Harvard’s Henry Kissinger.
Health policy goes global. As if to emphasize the convergence of the
two journals’ spheres of influence, the gathering featured a major
address by Cheryl Scott, who went from heading a Seattle health plan to
CEO of the Bill & Melinda Gates Foundation. The foundation, which
focuses on health disparities in the U.S. and abroad, has begun funding
Health Affairs to devote regular attention to the global scope of these
types of issues. Earlier in the day, Sir Donald Berwick, president of
the Institute for Healthcare Improvement, highlighted the way in which IHI has expanded internationally, including projects in South Africa and Malawi. Berwick
also pointed to IHI’s ongoing work on a hospital mortality measure with
Britain’s Sir Brian Jarman. (As an American citizen, Berwick actually
received only honorary knighthood, but since this blog owes its
existence to a Brit, it seemed acceptable to throw in the “sir.”)
The Internet changes everything and nothing. In its first quarter
century, Health Affairs published nearly 4,000 articles. In its next quarter century, that number will increase exponentially both because of the print publication’s greater frequency of publication and the move to publish some articles directly on the Web. The original circulation of a few thousand print subscribers has grown to more than 11,000 print and Web subscriptions, with a site that attracted over sixteen million page views in 2006. The journal even has a blog. What has not changed, however, is that timely and accessible content is important only if people want to read it. That, in turn, relates to both what is said and how it is said. Iglehart and his hand-picked successor, health economist James C. Robinson, share a deep understanding of this reality despite the stylistic differences of an ex-wire service reporter from Milwaukee and an academic superstar at University of California, Berkeley. John, as one colleague said in
tribute, is health care’s Columbo, the old-fashioned TV detective who
deceived the fast-lane bad guys with a pseudo-slow style that masked a
razor-sharp mind. Jamie in my view, is more likely to suggest
CSI:Miami’s David Caruso.
The difference between “medicine” and “health care.” The major sponsors
of the 2007 Health Policy Summit and a subsequent dinner gala were
foundations, health plans and drug companies. In the sixth and lowest
tier of sponsorship, forking over chump change of ten grand each, were
the American Hospital Association, the American Academy of Family
Physicians and the Association of American Medical Colleges. On
reflection, this makes sense, given that the central problem in health
care policy is the unrestrainable and unjustifiable growth in the cost
of care prescribed by doctors and frequently delivered by hospitals.
Put another way, health plans have prospered as the cost controllers;
providers have suffered as the cost controllees. As for drug companies,
they’re the savvy guys who spread their bets, ensuring an open door and
a welcoming ear no matter who’s in power.
The unvarying persistence of practice variation. Dartmouth’s John
Wennberg, founder of the Center for the Clinical Evaluative Services,
was honored as the most influential health services researcher over the
past 25 years. Truth be told, he published his first paper on practice
variation in 1973, but didn’t hit the “big time” until a prescient
Iglehart devoted the journal’s second-ever theme issue to “variations
in medical practice” in 1984. Congress immediately responded with
hearings, and, struck by the enormous potential of consistently
appropriate medical practice to save money and save lives, eventually
decided to study the problem some more. This, in turn, paved the way
for Wennberg’s son, David, to grow up, go to medical school and start
publishing practice variation studies of his own. HealthDialog, where
David Wennberg is a senior executive, is an outgrowth of the non-profit
Dartmouth center founded by Jack. It’s unclear whether any of David’s
children will continue in the family business, but neither Wennberg
père nor fils seemed worried that practice variation will have
successfully been addressed between now and the time they finish high
school, college, medical school and post-graduate residency and
Over the past quarter century, the advent of a large and highly trained health care research community has meant a dramatic improvement in the ability to point out inefficiencies in the health care system, such as practice variation; to document in ever greater detail the economic and human costs; and to suggest a range of possible solutions. But the success that health researchers have had in persuading policymakers to adopt these proposed solutions, many of which engender strong political opposition, is probably equivalent to the influence that experts in foreign affairs have had in persuading the United States to adopt a rational course in foreign policy.
As for health researchers’ impact on the public – did I mention that
the United States does not yet have universal health insurance? But,
of course, that’s no reason not to continue trying.
Michael L. Millenson, whose 25 years in
health care began in 1982, is president of Health Quality Advisors LLC
in Highland Park, IL.